ODJFS TANF Non-Assistance Eligibility Form for TANF Funded Services
This Application is to be completed by the applicant/participant who is a parent of a minor child age 17 or younger, or 18 and in high school.
Name of Applicant
Social Security
Phone Number
Address
Street Address
Street Address Line 2
City
State
Zip Code
Is the applicant/individual/family member a United States Citizen?
Yes
No
Does the applicant meet one of the Citizenship exceptions under Ohio Administrative Code 5101:1-2-30
Yes
No
Number of household members
Please Select
1
2
3
4
5
6
7
8
9
Is the family’s total income at or below 200% of the Federal Poverty Level based on household size?
Yes
No
Full Name of Minor in Household
First Name
Last Name
Age
Full Name of Minor in Household
First Name
Last Name
Age
The family requesting services includes:
Custodial parent (mother, father, adoptive mother, adoptive father, or relative of a dependent child under 18 (orunder 19 who is still a full-time student in high school or at the equivalent level of vocation or technical training),who has never been married or whose marriage was annulled and whose eligibility is being determined.
Non-Custodial Parent: the parent is not in the household of the child (see definition for child above) whoseeligibility is being considered. Both the non-custodial parent and the child must live in the State of Ohio.
Blood Relative: including those of half-blood, within the relationship of siblings, first cousins, nephews, nieces,aunts, uncles and individuals of preceding generations as denoted by prefixes of grand, great, great-great, etc.This group includes relatives within the fifth degree of kinship to the dependent child; therefore, this includes first cousins once removed, but not the second cousins.
The Provider is to review the following statements with the program applicant/participant
I understand that I am required by law to provide my social security number to receive TANF fundedbenefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137.)
I understand that I am required by law to provide my social security number to receive TANF fundedbenefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137.)
I certify to the best of my knowledge, the information included in this application is true, including income andcitizenship/qualified non-citizenship information.
I certify that as the parent or legal guardian of the minor child for whom service is being request, we have notfraudulently received benefits under the OWF and/or PRC programs, OR that we have repaid the cost of anyfraudulent assistance as defined in section 5101.83 Revised Code and rule 5101:1-23-75 of the OhioAdministrative Code.
Name
Social Security
Phone Number
Address
Street Address
Street Address Line 2
City
State
Zip Code
Signature
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: